Tania Cubison

The impact of recent legislation on paediatric fireworks injuries in the Newcastle upon Tyne region

Despite the changes to the UK fireworks laws and considerable efforts in prevention, children are still being injured by fireworks. The UK is one of many countries that have altered their firework laws in recent years. We reviewed 54 firework-injured children over the last 10 years and assessed the impact of the two recent UK law changes. Our study outlines past British firework legislation and reviews the literature. In November 1996, there were three deaths in England, Wales and Scotland due to fireworks. The British Government introduced the Fireworks (Safety) Regulations of 1996/1997, primarily banning banger fireworks (known as bangers). We have not seen banger injuries in Newcastle since then. The Fireworks Act 2003 and the Fireworks Regulations 2004 limited the sale of fireworks to the 3 weeks surrounding bonfire night, and banned under 18s from purchasing or possessing fireworks. In our series, we noticed that, in 2004, 83% of childrens firework injuries happened in the 3 weeks surrounding Bonfire Night. We conclude that legislation has had an impact, but stricter enforcement of the existing laws and further education of children and the general public into the dangers of fireworks is needed, as children are still being injured.

Evidence based management for paediatric burn: New approaches and improved scar outcomes

Little evidence has been produced on the best practice for managing paediatric burns. We set out to develop a formal approach based on the finding that hypertrophic scarring is related to healing-time, with durations under 21 days associated with improved scar outcome. Incorporating new advances in burn care, we compared outcomes under the new approach to a cohort treated previously. Our study was a retrospective cross-sectional case note study, with demographic, treatment and outcome information collected. The management and outcome of each case was assessed and compared against another paediatric burns cohort from 2006. 181 burns presenting across a six month period were analysed (2010 cohort) and compared to 337 children from a previous cohort from 2006. Comparison of patients between cohorts showed an overall shift towards shorter healing-times in the 2010 cohort. A lower overall rate of hypertrophic scarring was seen in the 2010 cohort, and for corresponding healing-times after injury, hypertrophic scarring rates were halved in comparison to the 2006 cohort. We demonstrate that the use of a structured approach for paediatric burns has improved outcomes with regards to healing-time and hypertrophic scarring rate. This approach allows maximisation of healing potential and implements aggressive prophylactic measures.

The tertiary management of pretibial lacerations

Pretibial lacerations remain one of the commonest yet most neglected conditions facing emergency departments and plastic surgeons alike. Furthermore, these injuries afflict the most vulnerable groups of adults - the elderly and the infirm. It is essential therefore to have an approach to pretibial lacerations based on best available evidence, in order to optimize wound outcomes, but perhaps more importantly, to safeguard the general health of the vulnerable individual. We present an evidence-based approach to the tertiary management of these injuries and propose a treatment algorithm that we have utilized in our unit to successfully manage 40% of tertiary referrals of pretibial lacerations in a conservative manner.

Pediatric superficial scald burns--reassessment of our follow-up protocol.

The most common pediatric burn injury is a superficial scald. The current follow-up protocol for such burns includes review of the patient at 2 weeks postinjury and then 2 months later. The authors decided to review the protocol to assess the need for this second follow-up. A retrospective study reviewed the case notes of patients younger than 16 years at the time of their injury presenting with a scald over 5% TBSA. The progress of healing and scar development up to 5 years follow-up was assessed. This study showed that scalds healing within 2 weeks following injury rarely became hypertrophic. A prospective study was performed over a 10-month period. All children who suffered a superficial partial-thickness scald injury were included. At the 2-week appointment, the need for further follow-up was predicted. The accuracy of this prediction was assessed 2 months later. This study showed that an experienced member of the burns team could reliably predict at 2-week appointment those children who could be safely discharged with no subsequent need for scar management. This study suggests that it will be safe to modify the follow-up protocol, reducing the number of clinic attendances.

A novel technique of NexoBrid™ application to burns on the hands

The use of NexoBrid in the treatment of burns is increasing in the United Kingdom following recent publications that highlight the benefits of dermal preservation. Consequently, this is now thought to reduce skin grafting [1,2]. The use of Nexobrid may reduce the likelihood of a surgical procedure but it still needs specialist input that is particularly important for pain management [3]. We present a technique for effective Nexobrid application, an area that receives much less attention in the literature. Effective application of Nexobrid is clearly an important aspect to the treatment and there is much discussion between specialist units on the best approach to take. One of the issues relates to protection of the unburned skin surrounding the treated burn area. Vaseline is currently recommended, but other barriers such as Jelonet can be easier to apply. Our own experience suggests other approaches could also be helpful, such as using occlusive hydrocolloid dressings (e.g Duoderm) to minimise trauma to intact skin and provide an impermeable barrier for the duration of Nexobrid treatment. When Nexobrid is applied it is often a thick gel. It then becomes much less viscous and can result in leakage from the dressings. Many units use occlusive dressings [1,3,4] to contain the fluid, but in certain areas this may be challenging. Our approach for hand burns is simple. We use clear plastic gloves sealed at the wrist with tape to prevent leakage. This allows hand movement and direct observation whilst also being very easy to apply. By containing the Nexobrid we feel that we can gain maximal benefit by avoiding loss of the enzyme and reducing the complexity of the dressing. We feel that these small modifications have a significant impact on the effectiveness of Nexobrid and ultimately the aim of effective debridement with maximal dermal preservation. R E F E R E N C E S

Systematic review: Early versus late dangling after free flap reconstruction of the lower limb

INTRODUCTION AND AIMS Dangling regimes after free flap surgery to the lower limb vary between centres and clinicians. There is currently no accepted gold standard. This review examines the evidence for early versus late post-operative dangling after free flap reconstruction of the lower limb. The secondary aim is to evaluate the regimes used. MATERIAL AND METHODS Medline, Embase and the Cochrane library were searched for all studies on dangling or rehabilitation after free flap reconstruction in the lower limb (December 2015). All studies outlining a clear dangling regime were included. Data were extracted by two authors independently and analysed using the software package Review Manager (RevMan 5). All authors were contacted for further information. RESULTS 197 patients were included from 8 studies: 1 randomized, 6 cohort and 1 case-series. Although some studies did not state the aetiology, of those that did; 42% were trauma, 31% oncology, 20% complex wounds and 7% infection. The majority of flaps were latissimus dorsi, 18% parascapular, 15% anterolateral thigh and the remainder was mixed. Forty-eight percent of patients dangled on post-operative day (POD) 7, 29% on day 6, 4% on day 5 and 18% on day 3, with varying regimes. A meta-analysis of comparable studies showed circulatory benefit after 4 days of dangling using tissue oxygen saturation as a measure. Four flap failures (2.0%) were reported. CONCLUSIONS There is physiological benefit in post-operative dangling. A 3-day flap training regime is sufficient for physiological training. However, the optimal flap training regime remains unclear. It may be appropriate to start dangling as early as POD 3. More research is needed to determine the optimal time to start dangling and the regime.

The vascular supply of muscles in war injuries: a century on

Sir, Campbell and Pennefather, British Army surgeons during the First World War, originally identified varying patterns of vascular supply to muscles based on angiography. They suggested that following an injury, an understanding of the normal pattern of blood supply to a muscle would aid both prediction of potential of its survival following debridement and liability to the development of gas gangrene [1]. Seven decades later, Mathes and Nahai, moving forward from the early radiographic findings of Campbell and Pennefather, formally established the vascular anatomy of muscles using latex barium injection studies, further refining their classification. Mathes and Nahai identified five patterns of supply and further highlighted the potential value of knowledge of vascular patterns to the reconstructive surgeon [2]. An understanding of blood supply allowed successful transposition of muscles to cover soft tissue defects at a different location, either by rotation on a pedicle or through free tissue transfer. Nearly 100 years after being described, an understanding of the vascular supply of muscles remains as crucial as ever in the debridement and reconstruction of war-related injuries. In recent conflict, blast injury has led tomassive zones of trauma, with both widespread direct damage to the tissues as well as more proximal injury. The shearing effect of the blast wave causes damage to vascular pedicles, as well as leading to retained contamination far more proximally than might be expected. The focus of initial debridement has been to remove gross contamination and clearly nonviable tissue. Debridement can be very aggressive in the mangled lower limb, while a more conservative approach may be taken in areas such as the hands, where important structures are preserved to maintain future function. Conservation of limb length is a high priority in amputees, such as achieving a trans-tibial over a trans-femoral final level, due to the significant functional benefit. An understanding of the excellent reliability of the proximal blood supply of gastrocnemius can help the debriding surgeon to confidently retain this muscle even if its only remaining blood supply is via the proximal pedicle. However, more caution is required with other muscles, such as soleus, with a less dominant blood supply that may not survive on a proximal pedicle alone [3]. This knowledge is invaluable when planning an elective transtibial amputation after a failed attempt at limb salvage, where a bulky poorly perfused soleus can cause healing difficulties and an unsatisfactory residual limb. The complexity of injury in military patients dictates that the reconstructive surgeon should not limit himself to traditional donor sites, as these may significantly impact function, and thus be inappropriate, or simply be unavailable. For example, the use of latissimus dorsi will lead to far greater functional deficit in a bilateral trans-femoral amputee than in a lady who has undergone breast reconstruction. The rectus abdominus muscle is vital for core stability and is an equally poor donor site for an amputee. The understanding of the pattern of blood supply can allow unconventional muscles to be used for free tissue transfer. Figures 1 and 2 show a redundant semitendinosus muscle harvested from the contralateral trans-femoral amputation, to cover an exposed intramedullary tibial nail. Prior to the increased use of prophylactic anti-fungal agents in combat troops injured in Afghanistan, a J. A. Jeevaratnam (*) : T. C. S. Cubison Queen Victoria Hospital NHS Trust, Holtye Road, East Grinstead, West Sussex RH19 3DZ, England e-mail: jeevaj@doctors.org.uk